Barriers and facilitators of parent−adolescent communication on sexual health and relationships among the UK population: A study protocol

Abstract Background and Aims Improving the sexual and reproductive health of adolescents remains a public health priority. Effective communication between parents and adolescents regarding sexual health and relationships is important and could influence adolescents to adopt safer sexual behaviors. However, several barriers can impede this communication in the UK population. The aim of the review is to explore barriers and facilitators, as well as wider determinants of parent–adolescent communication (PAC) on sexual health and relationships. The review will explore possible interventions aimed at promoting PAC on sexual health and relationships. Methods The review will focus on exploring barriers and facilitators of PAC on sexual health and relationships in the United Kingdom. This study will synthesize qualitative literature to understand the significance of parent–adolescent sexual and reproductive health communication, the challenges and facilitators to effective communication in the United Kingdom. Using a detailed predetermined search strategy, the study will search for relevant studies from CINAHL, MEDLINE, PsycINFO, EMBASE, SCOPUS, Web of Science, and gray literature on Google Scholar. The Critical Appraisal Skills Program checklist will appraise the included studies' methodological quality. A thematic synthesis approach will be used to synthesize data from included studies. Conclusion Findings from the systematic review are expected to give information on the barriers and facilitators of PAC on sexual health and relationships which will further optimize interventions to improve this type of communication and guide future research in understanding this area. Systematic review registration The review has been registered with the International Prospective Register of Systematic Reviews CRD (PROSPERO) (CRD42022351697).


| BACKGROUND
Adolescent Sexual and Reproductive Health Education is an essential concern to the public health sector as over one-sixth of the world's population are adolescents. 1The World Health Organization (WHO) 2 has defined adolescents as individuals aged 10-19 years.Nearly half of the world's total population are young people under 25 years of age. 3 Adolescence is a time characterized by physical, emotional, and psychological changes that can cause young people to be vulnerable to health and social problems. 4Equally, according to the WHO, sexual health is not just the absence of disease, malfunction, or infirmity but also a condition of physical, emotional, mental, and social well-being in relation to sexuality. 2e parent-adolescent dyad about communication on relationships and sexual health has become a contemporary public health issue as studies have shown it is effective in setting a solid foundation for an adolescent to have good sexual health and sexual behavior. 4,5er the last few years, sexual activity around the globe has been on a steady rise among the adolescent population, 6,7 which makes Adolescent Sexual Reproductive Health (ASRH) a global Public Health issue.
Approaches to promote healthy adolescent sexual behavior in the United Kingdom includes sexual education, policy frameworks, over-the-counter contraceptives, sexual health clinics, and access to sex and sexuality information. 4,810][11][12] Findings from the literature point to how family systems serve as the central agent of socialization for children. 4,12The premise on which the aforementioned occur is that parents are in regular proximity and contact with their children, thus can shape their behavior, provide guidance, and influence social contexts in which they develop. 4In their study, Downing et al. 13 further add that parent-adolescent communication (PAC) timing is critical, highlighting that communication that occurs before adolescents begin engaging in sexual activities is more effective.
Poor PAC has been identified to have numerous potential risk factors. 14,15One is parental awareness, while others are cultural concerns like parents feeling embarrassed. 47][18] As a result, most teenage sexual issues are typically misdirected by their sex-specific peer groups. 19The topic of conversation, 20 parents' self-efficacy for communication, 21 parent-adolescent relationship, 22 communication patterns, 23 media, 24,25 and peer group factors are just a few of the factors that have been shown in prior research to influence PAC about sexuality.
Results from research suggest that parents in high-resource settings, including Europe and America, are comfortable and have open conversations about sex and Sexual Reproductive Health (SRH) issues with their adolescent children. 267][28][29] However, findings from existing studies on PAC in the United Kingdom have suggested otherwise. 20common theme discovered across the UK is that discussions between parents and adolescents on SRH issues occur but not often and are characterized by parents feeling unprepared and unable to address the sensitive matters around sex, sexuality, and other SRH issues. 20Also, recent studies around PAC in the United Kingdom have focused on digital sexual health interventions, 30 with limited evidence existing about the barriers and facilitators of PAC in the United Kingdom.This systematic review aims to highlight barriers and facilitators to PAC, particularly in the United Kingdom.
Additionally, the review will explore the wider determinant factors influencing this communication.

| Protocol and registration
The review protocol has been carried out under the guidelines of the preferred reporting items for the Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) checklist. 31,32The review has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) CRD42022351697.The protocol states the objectives and methodology to be conducted and focuses on exploring the barriers and facilitates influencing PAC on sexual health and relationship.Additionally, this review will examine the wider determinant factors influencing this communication.

| Search strategy
A comprehensive electronic literature search will be carried out to explore the barriers and facilitators influencing PAC on sexual health and relationship.Although there are other databases on this topic, the following electronic databases will be searched: CINAHL, MED-LINE, PsycINFO, EMBASE, SCOPUS, Web of Science, and Google Scholar.These databases will be investigated using a comprehensive search approach/keyword.The selected databases are one of the largest databases that holds robust information pertaining to the proposed topic of interest.The rationale for searching these databases is to ensure access to specialized, quality-controlled literature spanning various disciplines offering advanced search options, full-text access, citation tracking, alert for efficient, and thorough literature reviews.Gray literature (non-published, internal, or unreviewed articles, repositories) will also be searched.The reference lists of selected systematic reviews will be examined to determine whether they contain relevant papers that could be included in the review.Two researchers (L.J. and P. N.) will search the databases independently.The search terms that will be used in the search are related to "parents," "adolescents," "communication," "sexual health," "barriers," "facilitators," and the United Kingdom."These keywords will then be combined using Boolean operators "AND" and "OR."The Medical Subject Headings (MeSH) will also be utilized when searching various databases.The researchers will use the truncation signal (asterisk *) to search for all term alternatives.Supporting Information S1: Appendix Table 2 shows the preliminary search technique.

| Eligibility criteria
The studies involving parents of UK adolescents who have had sexual health communication with their adolescents will be included in this review.The United Kingdom is a suitable choice for studying barriers and facilitators of PAC on sexual health and relationships among the population for several reasons.First, the UK has a diverse population, allowing a broad range of perspectives to be studied.Additionally, the UK has a wellestablished National Health Service, which provides sexual health services and resources and a strong emphasis on sex education in schools.Furthermore, there is a wealth of existing research on sexual health and relationships in the United Kingdom, providing a foundation for further study.Additionally, the UK has a history of social and cultural changes regarding sexual health and relationships, which allows for exploring the impact of these changes on PAC.Thus, the studies that will be included in this review will define PAC, and studies have identified common barriers and facilitators of PAC on sexual health and relationship.
Studies published between 2015 and 2023 will be included as the field of ASRH has emerged over the last few years.Studies eligible will only be in English as authors are proficient in the language.This review excludes commentaries, editorials, symposium proceedings, and systematic reviews.Supporting Information S1: Appendix Table 1 demonstrates the inclusion and exclusion criteria using the population, interest, and outcomes (PIO) framework.

| Selection of studies and screening
The records exported from all electronic databases will be managed using a systematic review management software Covidence. 33,34The initial stage of the selection process will involve screening the title of retrieved articles based on the predetermined inclusion and exclusion criteria following the removal of duplicates.
The selected studies will subsequently be screened based on their abstracts at the second stage.Finally, full text of selected studies will be retrieved and evaluated against the inclusion and exclusion criteria.A predefined screening criteria will be developed to ensure the consistency of screening articles across the two reviewers (L.J. and P. N.), and pilot testing will be undertaken according to the eligibility criteria.Following the examination of the studies to determine the papers' eligibility, both reviewers will define outcome measures.Each reviewer will provide substantial reasoning for excluding studies.In a consensus meeting, a third reviewer will address any disagreement between the two reviewers.The third reviewer will be consulted to determine whether the study fits the inclusion eligibility criteria.
The PRISMA flowchart diagram (Figure 1) 35 will be used to show the study selection process.The studies that will be determined to be included will move to the methodological quality appraisal stage.

| Data extraction and management process
Two independent reviewers (L.J. and P. N.) will use the Joanna Briggs Institute Data Extraction Form for Review for Systematic Reviews and Research Syntheses to extract data for the eligible/ included studies. 36The data extraction tables of both reviewers will be compared to ensure that the systematic review contains all significant findings.A third reviewer will be involved if discrepant information is detected during the data extraction procedure.
separately.In the event that two reviewers disagree, a third reviewer will be consulted.An additional table will contain information regarding the risk of bias for each of the listed studies.

| Data synthesis strategy
First, a narrative synopsis of the review's results will be provided.
Following this, we will perform a descriptive analysis of all the final included studies to detail their characteristics, such as research title, authors, publication year, study objective, study methodologies, sampling technique, participant characteristics, and study outcomes.
A thematic synthesis 38 will be undertaken in which the final studies will be categorized according to themes.The structure will be modified in accordance with emerging new themes.The thematic synthesis will be carried out using Thomas and Harden's thematic synthesis method. 38This will be used to extract underlying meanings from qualitative data, create analytical themes, and draw conclusions across studies.After becoming familiar with the data in the included studies, an inductive line-by-line coding approach will be used in this study. 38Some studies may not directly address the review questions; hence, this method will favor the data extraction based purely on review questions.
There are three stages to the thematic synthesis process: (i) Relevant qualitative data will be coded line-by-line as free codes, which will be named according to their meaning and substance; (ii) free codes are then looked at to see how they relate to one another and are classified into descriptive categories; (iii) analytical themes for thematic synthesis will emerge based on the underlying meanings of the descriptive categories.The coding will be carried out by the reviewer L. J., which was approved by the review team after a discussion with one additional reviewer (P.L. N).Analyzing linkages  35 and interconnectivity led to synthesizing analytical themes and their subthemes will be carried out by L. J. and P. L. N Later, the reviewers will document their interpretations of the findings to identify emergent trends.Finally, the reviewers will emphasize possible facilitators and barriers to PAC on sexual health and the wider determinant factors influencing this communication.

| DISCUSSION
There is a need for a deeper understanding of the potential U R E 1 PRISMA database search flowchart for studies.Adopted from Page et al.
facilitators and inhibitors influencing PAC on sexual health and relationship in the United Kingdom.The protocol will lead to a systematic review that synthesizes evidence on these barriers, facilitators, and other wider determinant factors.The review will expand our knowledge of how parents can overcome these barriers, including stigmatization, discrimination, fear of refusal, lack of privacy, and confidentiality.The results of a systematic review will be made available to the public.AUTHOR CONTRIBUTIONS Laura O. Joseph: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization; writing-original draft; writing-review and editing.Pascal L. Navelle: Data curation; formal analysis; investigation; methodology; software; validation; writingreview and editing.Chinwendu C. Ngozi: Project administration; validation; visualization; writing-review and editing.Dorothy Hannis: supervision.Rebekah McNaughton: Supervision; visualization; writing-review and editing.Lawrence A. Nnyanzi: Supervision; validation; visualization; writing-review and editing.